trose45116
Expert
is this a level 2 visit?
Chief Complaints:
1. Left elbow pain.
HPI:
Appointment type:
New patient - Self referred Patient is a 49-year-old female who comes in with chief complaint of left elbow pain. She was involved in a motor vehicle accident on April 22, 2015. She was hit on the driver's side by a Fed ex truck. She feels that she struck her left elbow against the door or window. She has been doing physical therapy on the elbow. She feels like something is in her elbow. She is not pleased. She is not had any previous elbow issues. She describes the pain as being a 3 on a 1-10 scale. She denies any overt weakness in the elbow. She describes the symptoms as being aching. She did not had an injection. She did have x-rays. She did not have an MRI..
ROS:
General/Constitutional:
Denies Thirst - Excessive. Denies Chills.
ENT:
Denies Ear Discharge. Denies Bleeding Gums. Admits Blurred Vision.
Respiratory:
Denies Coughing. Denies Hemoptysis. Admits Shortness of Breath.
Cardiovascular:
Denies Tachycardia. Denies Circulation Problems.
Gastrointestinal:
Denies Bowel Changes. Denies Constipation.
Genitourinary:
Denies Blood in Urine. Admits Frequent Urination. Denies Painful Urination.
Musculoskeletal:
Denies Arthritis, denies. Denies Back Pain, denies.
Skin:
Denies Dry/Sensitive Skin. Denies Rash.
Neurologic:
Denies Coordination Problems. Denies Memory loss. Denies Seizures.
Psychiatric:
Admits Anxiety. Denies Depression.
Family History:
diabetes, HTN.
Social History:
tobacco- no
alcohol- no.
Medications: None
Allergies: N.K.D.A.
Objective:
Vitals: Wt 115 lbs, BMI 19.13 Index, Ht 5 ft 5 in.
Physical Examination:
Examination of the left upper extremity reveals no evidence of skin abnormality. No specific swelling about the elbow. Relatively full elbow range of motion. No pain with palpation laterally over the epicondyles or medially. Negative Tinel's the cubital tunnel. Elbow stable to varus and valgus stress at 0 and 30?. No evidence of PLRI. No pain with palpation about the triceps. Good grip strength. EPL, FPL, interossei firing. Intact sensation that entire left upper extremity. Radial pulse 2+.
Assessment:
Assessment:
1. Left elbow pain - M25.522 (Primary)
Plan:
1. Left elbow pain
Notes: X-rays of the elbow showed no evidence of fracture. No dislocation. No loose bodies noted.
At this point I would like to obtain an MRI. She is complaining that she feels like something is in her elbow. I want to rule out a loose body. I will see her back after the studies been performed. All questions were answered.
Follow Up: after MRI
Chief Complaints:
1. Left elbow pain.
HPI:
Appointment type:
New patient - Self referred Patient is a 49-year-old female who comes in with chief complaint of left elbow pain. She was involved in a motor vehicle accident on April 22, 2015. She was hit on the driver's side by a Fed ex truck. She feels that she struck her left elbow against the door or window. She has been doing physical therapy on the elbow. She feels like something is in her elbow. She is not pleased. She is not had any previous elbow issues. She describes the pain as being a 3 on a 1-10 scale. She denies any overt weakness in the elbow. She describes the symptoms as being aching. She did not had an injection. She did have x-rays. She did not have an MRI..
ROS:
General/Constitutional:
Denies Thirst - Excessive. Denies Chills.
ENT:
Denies Ear Discharge. Denies Bleeding Gums. Admits Blurred Vision.
Respiratory:
Denies Coughing. Denies Hemoptysis. Admits Shortness of Breath.
Cardiovascular:
Denies Tachycardia. Denies Circulation Problems.
Gastrointestinal:
Denies Bowel Changes. Denies Constipation.
Genitourinary:
Denies Blood in Urine. Admits Frequent Urination. Denies Painful Urination.
Musculoskeletal:
Denies Arthritis, denies. Denies Back Pain, denies.
Skin:
Denies Dry/Sensitive Skin. Denies Rash.
Neurologic:
Denies Coordination Problems. Denies Memory loss. Denies Seizures.
Psychiatric:
Admits Anxiety. Denies Depression.
Family History:
diabetes, HTN.
Social History:
tobacco- no
alcohol- no.
Medications: None
Allergies: N.K.D.A.
Objective:
Vitals: Wt 115 lbs, BMI 19.13 Index, Ht 5 ft 5 in.
Physical Examination:
Examination of the left upper extremity reveals no evidence of skin abnormality. No specific swelling about the elbow. Relatively full elbow range of motion. No pain with palpation laterally over the epicondyles or medially. Negative Tinel's the cubital tunnel. Elbow stable to varus and valgus stress at 0 and 30?. No evidence of PLRI. No pain with palpation about the triceps. Good grip strength. EPL, FPL, interossei firing. Intact sensation that entire left upper extremity. Radial pulse 2+.
Assessment:
Assessment:
1. Left elbow pain - M25.522 (Primary)
Plan:
1. Left elbow pain
Notes: X-rays of the elbow showed no evidence of fracture. No dislocation. No loose bodies noted.
At this point I would like to obtain an MRI. She is complaining that she feels like something is in her elbow. I want to rule out a loose body. I will see her back after the studies been performed. All questions were answered.
Follow Up: after MRI